ATI RN
Fundamental Concepts and Skills for Nursing 6th Edition Test Bank Questions
Question 1 of 9
What is the purpose of using warm IV fluids to help resuscitate clients in shock?
Correct Answer: B
Rationale: When a client is in shock, their body is not able to regulate its temperature effectively. In this situation, using warm IV fluids helps prevent hypothermia by providing the body with fluids at a temperature closer to the body's normal core temperature. Hypothermia can worsen the condition of a client in shock by further compromising their body's ability to maintain adequate perfusion and oxygen delivery to tissues. Therefore, utilizing warm IV fluids is essential in the resuscitation of clients in shock to help maintain their core body temperature within a suitable range.
Question 2 of 9
Which statements are correct regarding the various layers of the heart? Select all that apply.
Correct Answer: C
Rationale: The epicardium is the outermost layer of the heart and is also known as the visceral layer of the serous pericardium. It is a thin layer that covers the surface of the heart and is composed of connective tissue and fat. The epicardium helps to protect the heart and provides a smooth outer surface for the heart to move within the pericardial cavity.
Question 3 of 9
The nurse is preparing a patient for an intravenous pyelogram. What should be a part of the patient’s care at this time? Select all that apply.
Correct Answer: A
Rationale: A. Assess for allergies to seafood or iodine: It is essential to assess the patient for allergies to seafood or iodine because contrast material containing iodine is commonly used during an intravenous pyelogram (IVP). Allergic reactions to iodine can range from mild to severe, so assessing for allergies is crucial for patient safety.
Question 4 of 9
The nurse notes that the patient has a low calcium level and plans to assess for Chvostek’s sign. How will the nurse conduct this assessment?
Correct Answer: C
Rationale: Chvostek’s sign is an assessment technique used to detect hypocalcemia. The nurse will tap lightly over the facial nerve, just in front of the patient’s ear. A positive Chvostek’s sign is indicated by a twitching of the facial muscles on the same side of the face as the area that was tapped. This twitching is due to the hyperexcitability of the facial nerve, which can be a sign of low calcium levels. Therefore, option C is the correct way to conduct the assessment for Chvostek’s sign.
Question 5 of 9
A client with heart failure is admitted to the hospital for the placement of an implantable defibrillator. The client appears comfortable at rest, but displays dyspnea with activities of daily living (ADLs). Which stage of heart failure does the nurse recognize when reading the client's health record?
Correct Answer: C
Rationale: In stage III of heart failure, the client displays symptoms such as dyspnea, fatigue, and other symptoms with ordinary physical activity, known as NYHA Class III. This is consistent with the client's presentation of dyspnea with activities of daily living, indicating a moderate level of heart failure. The need for the placement of an implantable defibrillator also suggests a more advanced stage of heart failure compared to stage I or II. Stage IV is characterized by severe symptoms at rest, which the client does not exhibit based on the information provided.
Question 6 of 9
The nurse is providing care to a female client who is diagnosed with coronary artery disease. The client states to the nurse, "I don't know how this happened." Which response by the nurse is the most appropriate?
Correct Answer: A
Rationale: Option A is the most appropriate response by the nurse because it provides accurate information related to the client's concern about developing coronary artery disease. Studies have shown that women who take oral contraceptives have an increased risk of developing cardiovascular issues, including coronary artery disease. By providing this information, the nurse addresses the client's statement and educates her about a potential risk factor for the disease. This empowers the client with knowledge that can help her understand the possible reasons behind her diagnosis and make informed decisions about her health moving forward.
Question 7 of 9
What is the purpose of using warm IV fluids to help resuscitate clients in shock?
Correct Answer: B
Rationale: When a client is in shock, their body is not able to regulate its temperature effectively. In this situation, using warm IV fluids helps prevent hypothermia by providing the body with fluids at a temperature closer to the body's normal core temperature. Hypothermia can worsen the condition of a client in shock by further compromising their body's ability to maintain adequate perfusion and oxygen delivery to tissues. Therefore, utilizing warm IV fluids is essential in the resuscitation of clients in shock to help maintain their core body temperature within a suitable range.
Question 8 of 9
The nurse is planning care to reduce the risk of a patient in the intensive care unit from developing acute kidney injury. Which intervention should the nurse implement for this patient?
Correct Answer: C
Rationale: Acute kidney injury (AKI) is a common complication in critically ill patients in the intensive care unit (ICU). One of the primary interventions to reduce the risk of AKI is to maintain adequate fluid volume and cardiac output. Adequate hydration and adequate perfusion pressure are essential for renal function. Maintaining fluid volume and adequate cardiac output ensure that the kidneys receive enough blood flow and oxygen to function optimally. Conversely, inadequate fluid volume or low cardiac output can lead to decreased renal perfusion, predisposing the patient to AKI. Monitoring and optimizing fluid status and cardiac output are crucial in preventing AKI in high-risk patients in the ICU.
Question 9 of 9
The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status?
Correct Answer: A
Rationale: Encouraging oral intake of fluids when permitted is the most appropriate intervention to support the pediatric client's fluid status post-surgery. Adequate hydration is essential for the recovery process, and oral intake of fluids helps maintain fluid balance. Limiting oral and intravenous intake of fluids (option B) would not be beneficial in promoting hydration and recovery. Continuing normal saline administration even after oral intake is normal (option C) may lead to fluid overload. Converting the intravenous line to a saline lock immediately after surgery (option D) may not be ideal as the client may still need intravenous fluids to support hydration until they can tolerate oral intake effectively.